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RealSimulD said:
JD just dismissed personal choice - trying to tease it out could be cruel - I'm not straw manning. I'm responding to specifics.
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I didn’t dismiss anything at all. I literally said of course it’s part of the determinants of health. Literally in the post.

Guiding health care coverage policy by personal decisions can easily get into cruel territory. I just gave multiple examples. I’m sure you can think of hundreds more

I said the most obvious, least controversial statement ever lol. Surprised you’re taken aback
 
Mandelin Rain said:
When you look at disparities in health outcomes you can:

1. Play the eugenics game. Let’s just all advise against that.

2. Take the pessimistic view that people of a certain zip code or certain color or certain whatever are just hopelessly bad decision makers and that they are irredeemably causing their own health issues.

3. Take the optimistic view that no certain collection of people want to be chronically unhealthy and there are indeed systemic factors that push them toward poor health choices. Things like access to healthy food or primary care physicians. Things like low crime rates and quality education. If you take this view point, you believe you can impact health on a large scale.
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Agree with 1 not being an option.

I don't believe in 2 in the way you say it. I don't think all people with a certain level of income or certain zip code or certain whatever are hopelessly bad decision makers. I think that humans are remarkable at learning and then making better choices. I think humans are even better at being incentivized to learn and make better choices. Learning isn't going to come from a Eureka moment in the bathtub. It takes guidance and investment.

The full throated support of 3 reads to me (and I would love to be educated myself) that almost nothing is due to personal choice, it's all external, societal and has nothing to do with anything that an individual chooses to do day to day.
 
I don’t full throat support anything. I’m eminently open to being wrong about everything.

You can be given every advantage ever but if you start doing heroin, your health will suffer.

It’s always a mix.

When there’s literally no grocery store in your city but a fast food restaurant on every corner serving $1 double cheeseburgers and cokes, it’s REALLY hard to make good nutrition choices.

When you live next to Whole Foods and have a good income but eat at Zaxbys, well… that’s on you.
 
jondunn said:
I didn’t dismiss anything at all. I literally said of course it’s part of the determinants of health. Literally in the post.

Guiding health care coverage policy by personal decisions can easily get into cruel territory. I just gave multiple examples. I’m sure you can think of hundreds more

I said the most obvious, least controversial statement ever lol. Surprised you’re taken aback
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Your examples are, respectfully, garbage. I mean no disrespect, but they are trash. Respectfully.

If we aren't allowed to insure based on any risk factors at all, how does the insurance market work? It doesn't sound like insurance then. It sounds like subsidized medical care. And, I'm fine with that, but don't call it an insurance market. Luckily, smoking is allowed to be considered. Poor people also tend to smoke more, so are you saying we should remove this as something insurance can utilize for premiums? This is about as regressive as it gets - poor people smoke at WAY higher rates and then ACA allows insurers to charge 50% more in premiums. Need everyone to smoke less and have the opportunity / access for smoking cessation, with the incentive that you will pay less for insurance. Is that draconian?

I don't think someone with 5 speeding tickets in 2 years should get the same rates of insurance premiums as a prisitine driver, and they don't. So that is including personal choice. Yet, richer people get more speeding tickets but tend to have lower increases in their premiums than poor people. That's where societal failure comes into play. We can work on both, right? Be fairer with regards to changes in premiums and not be extra punitive to the poor, but also tell everybody to stop driving so ****ing fast (yes, that's you, Michigan drivers; I am getting passed on my right when I'm going 78 on the freeway).

In other insurance markets (life insurance, disability, auto), your personal choices matter and affect your premiums. Let's not get into putting people into box A or box B. Walk, chew gum, etc.
 
RickyScott said:
Number one cause of death and morbidity worldwide starting about 4 years ago is obesity. (Surrogates for excess nutrition include niddm and metabolic syndrome).
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Things are, and definitely will be, changing, including cancer incidences and death rates. How much will we be using RT for cancer in just 18 years when the top cancer diagnoses in order of incidence will be:

1) Breast
2) Melanoma
3) Lung (increasing Stage 1)
4) Colorectal (increasing colon vs rectal)
5) Renal
6) Liver
7) Leukemia
8) Uterus
9) Pancreas
10) Thyroid
...
14) Prostate

​

 
‘Let's not get into putting people into box A or box B’

Sounds like you agree!

‘It sounds like subsidized medical care’

Now you get it.
 
Mandelin Rain said:
I don’t full throat support anything. I’m eminently open to being wrong about everything.

You can be given every advantage ever but if you start doing heroin, your health will suffer.

It’s always a mix.

When there’s literally no grocery store in your city but a fast food restaurant on every corner serving $1 double cheeseburgers and cokes, it’s REALLY hard to make good nutrition choices.

When you live next to Whole Foods and have a good income but eat at Zaxbys, well… that’s on you.
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I am often wrong as often as I am right, but doesn’t stop me from having opinions.
 
also the fact that you can't seem to acknowledge that this is a slippery slope is alarming to me. You seem to have full throated belief in the private insurance system. good for you.

honestly if you ever decide to leave healthcare, you can make a lot of money lobbying for them
 
jondunn said:
also the fact that you can't seem to acknowledge that this is a slippery slope is alarming to me. You seem to have full throated belief in the private insurance system. good for you.

honestly if you ever decide to leave healthcare, you can make a lot of money lobbying for them
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I am pro single payor.

I am pragmatic about the world we live in. I do not believe in the current system, you are completely misunderstanding for me. We are in a private insurance system and if we have insurance, we should treat it as such.
 
RealSimulD said:
I am pro single payor.

I am pragmatic about the world we live in. I do not believe in the current system, you are completely misunderstanding for me. We are in a private insurance system and if we have insurance, we should treat it as such.
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If you are pro single payer, then the remainder of your posts do not jive, in my opinion.

You are correct, we are in a private insurance system. where we disagree, is that it seems to me that you are saying 'if we are private then we need to go full on private and prioritize profits over all other things' where I am saying there are ways to further regulate the current system to improve it.

Fundamentally we may disagree - as I view the move to eliminate pre-existing condition restrictions on insurance as a clear good thing, where you view it as unfair (based on your prior posts on this topic) and may see it as it is 'subsidized' health care.

We are all in a system where we all cover each other, even in a private insurance system. It is just that the government has to pay for all of the old and sick people right now whereas private insurance companies collect premiums from you and I and try to find ways to pay as little as possible for the sick people they do cover. A way to make it a better system would be put them all in one pool, so the government isn't making BCBS' or Aetna's life easier.


going back to a pre-2010 system and allowing insurance companies to deny care based on things that people have NO control over (like many pre-existing conditions) or giving them the creative license to decide what percentage of a heart attack was due to their smoking history and obesity and what percent to luck and what percent to family history (and whether or not family history is their fault) seems to be a) cruel but also b) insanely complex and ripe for abuse by insurance companies.

I firmly believe that even in a private system we should be making insurance comapnies work more and more for the customer, not less. I could care less about their profit margin. Why do you?
 
What he’s saying, is that given the current world we live in, people who dutifully pay their premiums are subsidizing those who don’t and sign up for insurance only once they are sick. In turn, it drives costs to the rule followers up. It’s a fair complaint.

Similarly, I don’t want to pay for my medical school AND your (not your, general your) medical school because you happened to choose to be employed by some not-for-profit-in-name-only university or health system for a few years out of residency.
 
Mandelin Rain said:
What he’s saying, is that given the current world we live in, people who dutifully pay their premiums are subsidizing those who don’t and sign up for insurance only once they are sick. In turn, it drives costs to the rule followers up. It’s a fair complaint.
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well sure it is a reasonable thing to bring up, though to me this seems to be the clear minority and a drop in the bucket. it's not that important IMO. far less than 1 percent I would have to imagine. and I don't think this is what he's talking about now, but in the conversation from last week or whatever, yes

but yes - even more reason that we should all be in one system.
 
and by that same logic, we should all be happy for evicore. why should i subsidize someone's health care because some rad onc wants to bill for 45 fractions?

If we go down that path, which I don't disagree with, it really is in ALL of our collective interests to reduce health care costs.
 
Mandelin Rain said:
When you are shot and killed at random in the subway, your health is adversely impacted not by a personal choice; rather a complete societal failure on gun regulation.

I think it’s fine for docs to be as against guns as cigarettes, f
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RealSimulD said:
Speaking of personal choice and all the fun Twitter action, where is @Chartreuse Wombat ? I was hoping for some insight from one of our wiser colleagues.
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Insightful? I doubt it.

1) Twitter/FB is garbage and I am glad that I never succumbed to it. The radiation oncology piece of Twitter is no different. Excellent recent piece by Jonathan Haidt in the Atlantic (attached at the risk of copyright infringement). I like his proposal (especially open primaries and rank voting)

2) The current health care system is not a market because of incomplete information (see Kenneth Arrow's original analysis from a long time ago).

3) I favor a single payor model but we live in a democracy constitutional republic and when single payor is on the ballot a clear majority don't vote in favor. Polls that ask a single question don't count.

I suspect this will be deleted since it is "political" but since you asked
 

Attachments

That Atlantic essay is so excellent and I think captures the angst many of us feel trapped between two extremes that none of us want or chose.
 



Are they going to go the way of United and do this for all radiation ?
 



good funding mechanism for some of you to consider!
 
TheWallnerus said:
I'm pulling a GD JD here. The converse of this sentiment would get you kicked out of med school.

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1650572694162.png

If this is the future, I'm gonna need to put all my money into hand lotion and turkey basters. maybe i'll open a store that sells them exclusively. right next to the rope store, which is next to the rickety stool store.
 
Ray D. Ayshun said:
View attachment 353691
If this is the future, I'm gonna need to put all my money into hand lotion and turkey basters. maybe i'll open a store that sells them exclusively. right next to the rope store, which is next to the rickety stool store.
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As it’s one of my favorite movies ever I will definitely join you at the Rope store! Oh wait.
8ABDF612-882D-4695-9DAB-CDBBD93E8672.jpeg
 
Rope projected cost $500,000 per yard in 5 years. Jokes on you if you think rope ownership is viable way out of this mess in the new economy.
 
jondunn said:
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Marijuana is still Schedule 1 despite what individual states choose to do with it. Opioids are Schedule 2.

Now I'm not saying race had nothing to do with it (because I can't know whether or not it did), but this isn't a great example to try and work with.

This sort of thing comes up in the pre-med/med student parts of the forums several times/year. The general advice is always the same "until marijuana isn't schedule 1 any more, its not worth the risk that the hospital might make a thing of it".
 
VA Hopeful Dr said:
Marijuana is still Schedule 1 despite what individual states choose to do with it. Opioids are Schedule 2.

Now I'm not saying race had nothing to do with it (because I can't know whether or not it did), but this isn't a great example to try and work with.

This sort of thing comes up in the pre-med/med student parts of the forums several times/year. The general advice is always the same "until marijuana isn't schedule 1 any more, its not worth the risk that the hospital might make a thing of it".
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Fine, but a hair test? Are we trying to keep people safe or are we just trying to screw people over? I get pee test, but hair goes back 90 days. For a “legal” drug.

I’m sure there may be an example, but what else is illegal at federal level, legal at state level, and can cause you to lose licensure / job?
 
There would be a lot fewer doctors in California if hair tests were routinely performed.

That being said, don’t be stupid. It’s not worth the risk.
 
DoctwoB said:
There would be a lot fewer doctors in California if hair tests were routinely performed.

That being said, don’t be stupid. It’s not worth the risk.
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Original Twitter post was in California, where if this is where it happened would be surprising.

I think like anything else, depends on the state
 
RealSimulD said:
Fine, but a hair test? Are we trying to keep people safe or are we just trying to screw people over? I get pee test, but hair goes back 90 days. For a “legal” drug.

I’m sure there may be an example, but what else is illegal at federal level, legal at state level, and can cause you to lose licensure / job?
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I suspect trying to make sure that someone didn't just stop doing the drug a day or two before the drug test if its a schedule drug test.
 
RealSimulD said:
Fine, but a hair test? Are we trying to keep people safe or are we just trying to screw people over? I get pee test, but hair goes back 90 days. For a “legal” drug.

I’m sure there may be an example, but what else is illegal at federal level, legal at state level, and can cause you to lose licensure / job?
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Agree. That is utter BS.
 
Some drugs such as amphetamines are only detectable in urine for about a day. Maybe 2-3 days. Without hair testing, I don’t know how you would catch these type of drugs
 
RealSimulD said:
What is to “catch”? Someone went to a bachelor party 2 months ago before graduation and had a candy?
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Seriously… everyone is obsessed with EBM. Would like to see some outcomes data justifying burning down someone’s career over a bad drug test result. Had a buddy who had this happen when starting residency. Was a bright kid… and never got a chance to apply is education, merely because he had a little too much fun post-match and got some bad advice on how long it would take to get it out of his system. Isn’t it remarkable how the most harmless illegal drug has the highest schedule and the worst pharmacokinetics?
 
RealSimulD said:
What is to “catch”? Someone went to a bachelor party 2 months ago before graduation and had a candy?
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I feel like speed is pretty addicting and probably not the best thing for drs to be doing often. Especially surgeons and such because it often makes people overestimate their abilities. Plus it’s easy to not sleep for 3-4 days while on it. Then they are too tired to do the work
 
Lamount said:
Seriously… everyone is obsessed with EBM. Would like to see some outcomes data justifying burning down someone’s career over a bad drug test result. Had a buddy who had this happen when starting residency. Was a bright kid… and never got a chance to apply is education, merely because he had a little too much fun post-match and got some bad advice on how long it would take to get it out of his system. Isn’t it remarkable how the most harmless illegal drug has the highest schedule and the worst pharmacokinetics?
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In my whole career... college, med school, residency, employment... I was never asked or required to do a drug test. David Sabiston (one of the biggest surgical names of the 20th century) was an alcoholic. Sigmund Freud was addicted to cocaine (he had recurrent oral cancer, and seemed to have an almost sadistic radiation oncologist though... so maybe his addiction was understandable, but would still be illegal today). Elon may expose us all to cocaine, at least us Coca-Cola lovers.
 
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RealSimulD said:
What slope are we worried about?

Every workplace has an impairment policy. If someone is acting a fool, test ‘em.

I don’t know how this actually helps safety.
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"Second key to success in this racket is this little baby right here. It's called cocaine. It'll keep you sharp between the ears"
 
jondunn said:
at the very least marijuana should be removed from the standard test.
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Definitely agree in states where it's legal.

Where it's illegal, I guess it may speak to some poor judgement and the likelihood of losing DEA if caught criminally. Not sure what the case law is regarding loss of prescribing right with a recreational amount of weed.
 
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